Andrew Morris Update on diagnosis and treatment of COVID-19

Asymptomatic infections are common

We now have two interesting cohorts, out of Iceland and Italy that about 43% of infections are in people with documented infection are asymptomatic. We don’t know how well this pairs with “infectious”, but it is a pretty impressive number nonetheless.

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Diagnosis and preventing spread with serology

This is one of these holy grails that has been, unfortunately ignored: people assume that serology will be really helpful, but experts keep telling us that it won’t be as useful as the epidemiologists think. There is a real chasm there. Here is one of several commentaries highlighting that very fact. It is not the most optimistic.

Health Canada has a long list of drugs used in critical care on Tier 3 status(i.e. running out!). This is emerging to be as big a deal (if not bigger) than PPE. It turns out that some COVID-19 patients require massive amounts of intravenous agents: paralytics, sedative, anxiolytics, and opiates. It is much more than we anticipated. This will not only affect, potentially, management of patients, but also ability to open up hospitals , and get back to operating.

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Serum therapy

The first serum therapy treatment trials are just starting in Canada: CONCOR-1 and CONCOR KIDs. A little known fact—you cannot collect or administer serum/plasma therapy in Canada outside of Canadian Blood Services. This trial is the only way you can get it.

The COVID-19 tragedy has moved from community—> hospitals, to a) long-term care and b) congregant settings (e.g. Shelters, Group Homes, Prisons, etc.). There are increasingly 2 epidemics in Canada, one being in these congregant settings. What we really have is an epidemic in the generally central society, and then another one in the marginalized society. This second epidemic is what will make our struggle to control COVID-19 all that much greater.

AHA Protected code blue algorithm and guideline

ACEi/ARBs may decrease mortality in patients with COVID-19

Preclinical studies suggest that ACEi/ARBs inhibitors may increase ACE2 expression in the CoV-2 virus, but it is unknown if this occurs in humans or is clinically relevant. The WHO has recommended not stopping ACE/ARBs in patients with COVID-19 despite some earlier recommendations to hold these drugs as a precaution. Newer evidence suggests that ACEi/ARBs may decrease mortality in patients with COVID-19. This recent retrospective, multi-center observational study in China of 1128 admitted patients with hypertension diagnosed with COVID-19, compared 188 patients taking ACEI/ARB to 940 patients not taking ACEI/ARB, found that the mortality rate was lower in the ACEI/ARB group versus the non-ACEI/ARB group after adjusting for age, gender, comorbidities, and in-hospital medications (adjusted HR, 0.42; 95% CI, 0.19-0.92; P =0.03). Remember, this is an observational study – we should not be starting all COVID patients on ACEi/ARBs based on this one study.

IO is probably a very good option for quick vascular access when wearing full PPE

A recent analysis of RCTs suggests that the use of PPE significantly reduces the efficacy of placing peripheral IVs (RR = 1.0; 95% CI, 0.93–1.08; I2 = 88%; p = 0.006) and extends the time to obtain access (MD = 9.37; 95% CI, 0.81–17.93; I2 = 98%; p < 0.001). They found that IO access was more effective (100% vs 90%) and faster (MD = −17.60; 95%CI,−19.44 to −15.76; I2 = 99%; p < 0.001). They also point out that IO may be associated with a lower risk of stabbing compared to IV.

The combination of hypogeusia and hyposmia may be helpful in ruling in COVID-19

In an observational study of 452 patients out of France who tested positive for CoV-2 by nasopharyngeal swab hypogeusia (lessened sense of taste) and hyposmia (lessened sense of smell) were strongly associated with COVID-19 diagnosis, separately and combined, in patients with and without a medical history of ENT disorders. A combination of hypogeusia and hyposmia in patients with no medical history of ENT disorders had a sensitivity of of only 42% but had and a specificity of 95%!

Should older healthcare workers and pregnant healthcare workers be excused from work during the COVID-19 pandemic?

People over the age of 60 (especially those with a history of heart/lung disease or cancer and those who are in an immunocompromised state) are at higher risk for both severe disease and mortality from COVID-19, with mortality rates as much 10 times higher in those between the ages of 60 and 69. The literature also suggests that pregnancy is a risk factor for severe disease and adverse fetal effects. ED administrators may consider offering shifts for these staff that do not include the “hot” and “warm” zones of their departments or suggesting that they refrain from ED shifts during the height of the pandemic.

Dr. Anton Helman is an Emergency Physician at North York General in Toronto. He is an Assistant Professor at the University of Toronto, Division of Emergency Medicine and the Education Innovation Lead at the Schwartz-Reisman Emergency Medicine Instititute. He is the founder, editor-in-chief and host of Emergency Medicine Cases.

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Emergency Medicine Cases (EM Cases) is a free online medical education podcast, medical blog and website dedicated to providing online emergency medicine education and CME for physicians, residents, students nurses and paramedics. We are Canada’s most listened to emergency medicine podcast with thousands of subscribers, well over 6 million podcast downloads since 2010 and are proudly part of the #FOAMed community. In each Main episode podcast 2 or more experts in a particular emergency medicine topic join Dr. Helman in a round-table, case-based discussion on key practice changing clinical emergency medicine topics, which are then carefully edited to maximize your learning. EM Cases’ Journal Jam podcast brings together world-renowned researchers and educators to keep you up to date on key research papers in EM, the EM Quick Hits podcast has 5 minute segments from 10 experts in specific challenging EM topics, and the Best Case Ever podcast has guest experts sharing their tacit knowledge on particularly interesting cases. We also offer the CritCases blog and Waiting to Be Seen blog as well as eBooks, Rapid Reviews Videos of the main episode podcasts, POCUS Cases videos, a Quiz Vault, and interactive courses.
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